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z g Waste Tire Suoy & Inspection Reporowspection Report Number <br /> ■ 911A State of California <br /> CIWMB 181e ) Survey Form - Page 1 I1 - 1141041 <br /> California Integrated WaststManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection I Inspection Type (Fill one) <br /> O U ! <br /> Site Suffix: d b () 0 Routine O Re-inspection O Referral O Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> i y <br /> Identifier: SrCkQo_ `,r O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name J V Inspected By Inspector <br /> AdI/� �y,��� a -s 3 _ o , <br /> �i Physical Address <br /> 1GY01 ;?6 <br /> CA 9s <br /> L�WI t4(/V Z3 C Inspection Date <br /> Time In / Time Out <br /> Business Rep Title 0 AM 0 AM <br /> d o2 ® PM 3 a S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)'i (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Passenger ® Generator I 0 Outdoor <br /> D O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — O Planned ® OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0-Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body 0 Car Dealer O Collection O Crumb Rubber <br /> 0 Service Station 0 Hauler Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> — - -- ---- -- - -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 j PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 : 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 0 Referred f CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: <br /> P � O y <br /> Comments Included: 06 3 <br /> Business Rep's gnature P on mber Inspector' gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'i� � !E X A P 13 <br /> White Copy:CIWMB Yellow Copy:Operator Pink 4py:, <br />